Form 1-NR/PY Mass. Nonresident/Part-Year Resident Tax Return 2016FIRST NAME M.I. LAST NAME

SPOUSE’S FIRST NAME M.I. LAST NAME

ADDRESS CITY/TOWN/POST OFFICE/FOREIGN COUNTRY STATE ZIP + 4

ADDRESS OF LEGAL RESIDENCE OR DOMICILE (IF FILING AS NONRESIDENT) CITY/TOWN/POST OFFICE/FOREIGN COUNTRY STATE OR FOREIGN COUNTRY

Fill in if (see instructions): Original return Amended return Amended return due to federal changeState Election Campaign Fund (this contribution will not change your tax or reduce your refund). . . . . . . . . . . . . . . $1 You $1 Spouse if filing jointly . . . . . TotalFill in if veteran of U.S. armed forces who served in Operation Enduring Freedom, Iraqi Freedom or Noble Eagle 3 You 3 Spouse 3 $If taxpayer(s) is deceased, fill in appropriate oval(s); see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Primary SpouseUnder age 18; see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 You 3 SpouseSelect only one: Nonresident Filing as both a nonresident and 3 Fill in if name/address has changed since 2015

Part-year resident part-year resident (see instructions) 3 Fill in if noncustodial parentNonresident composite return (see inst.) 3 Fill in if filing Schedule TDS (see instructions)

a Total federal income (from U.S. 1040, line 22; 1040A, line 15; 1040EZ, line 4; 1040NR, line 23;or 1040NR-EZ, line 7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 a

b Federal adjusted gross income (from U.S. Forms 1040, line 37; 1040A, line 21; 1040EZ, line 4;1040NR, line 36; or 1040NR-EZ, line 10). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 b

1 FILING STATUS 3 Single Married filing joint return (both must sign return)(select one only) Married filing separate return (enter spouse’s name and Social Security number in the appropriate spaces above)FILING STATUS 3 Head of household (see instructions) You are a custodial parent who has released claim to exemption for child(ren)

2 PART-YEAR RESIDENTS ONLY

Dates as Massachusetts resident: From 3 To 3

3 Total days as Massachusetts resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ÷ 365 = 3 3

4 EXEMPTIONSa. Personal exemptions. If single or married filing separately, enter $4,400. If head of household, enter $6,800. If married filing jointly, enter $8,800 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4a

b. Number of dependents. (Do not include yourself or your spouse.) Enter number 3 × $1,000 = 4bYou must enclose Schedule DI.

c. Age 65 or over before 2017: You Spouse Enter number 3 × $ 700 = 4c

d. Blindness: You Spouse Enter number 3 × $2,200 = 4d

e. 1. Medical/Dental 3 2. Adoption 3 1 + 2 = 4e

From U.S. Schedule A, line 4 See instructions

f. TOTAL EXEMPTIONS. Add lines 4a through 4e. Enter here and on line 22a. . . . . . . . . . . . . . . . . . . . . . . 3 4f

INCOMENonresidents report in lines 5 through 11 Massachusetts source income only. Use line 13 if appropriate. Part-year residents report inlines 5 through 11 income earned and/or received while a resident. Do not use lines 13 or 14. If filing both as a nonresident and part-yearresident, be sure to complete and enclose Schedule R/NR, Resident/Nonresident Worksheet, before proceeding any further.

5 Wages, salaries, tips and other employee compensation (from all Forms W-2) . . . . . . . . . . . . . . . . . 3 5

SIGN HERE. Under penalties of perjury, I declare that to the best of my knowledge and belief this return and enclosures are true, correct and complete.Your signature Date Print paid preparer’s name Preparer’s SSN

/ / or PTIN 3

Spouse’s signature (if filing jointly) Date Paid preparer’s phone Paid preparer’s

/ / ( ) EIN 3

May DOR discuss this return with the preparer? 3 Yes 3 Paid preparer’s signature Date Fill in if self-employedI do not want my preparer to file my return electronically 3 / /

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1. YOUR SOCIAL SECURITY NUMBER

2. SPOUSE’S SOCIAL SECURITY NUMBER

FILE YOUR RETURN ELECTRONICALLYFOR A FASTER REFUND. GO TOMASS.GOV/DOR FOR MOREINFORMATION.

CERTAIN PART-YEAR RESIDENTS MUST ENCLOSE

SCHEDULE HC

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SOCIAL SECURITY NUMBER

6 Taxable pensions and annuities (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6

7 a. 3 – b. 3 . . . . . . . . . . . . . . . a – b = 7Massachusetts bank interest Exemption amount

Exemption: if married filing jointly, subtract $200 from line 7a; otherwise subtract $100 and enter result (not less than “0”).

8 Business/profession or farm income/loss (enclose Massachusetts Schedule C or U.S. Schedule F). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 8

9 If you are reporting rental, royalty, REMIC, partnership, S corporation, trust income/loss,see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9

10 a. Unemployment compensation. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10a

b. Massachusetts state lottery winnings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10b11 Other income (alimony, taxable IRA/Keogh distribution, winnings, fees) from Schedule X,

line 5 (enclose Schedule X; not less than “0”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 11

12 TOTAL 5.1% INCOME. Add lines 5 through 11. (Be sure to subtract any loss(es) in lines 8 or 9) 12

13 NONRESIDENT APPORTIONMENT WORKSHEET. You cannot apportion Massachusetts wages as shown on Form W-2. Do not use this work-sheet if you know the exact amount of your Massachusetts source income. Use only when income from employment/business is earned bothinside and outside Massachusetts and the exact Massachusetts amount is not known.Basis: working days miles sales other:

a. Working days (or other basis) outside Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13a

b. Working days (or other basis) inside Massachusetts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13b

c. Total working days. Add line 13a and line 13b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13c

d. Nonworking days (holidays, weekends, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13d

e. Massachusetts ratio. Divide line 13b by line 13c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 13e

f. Total income being apportioned (you cannot apportion Mass. wages as shown on Form W-2) . . . 13fg. Massachusetts income. Multiply line 13e by line 13f. Enter here and in appropriate lines on

pages 1 and 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13g

14 NONRESIDENT DEDUCTION & EXEMPTION RATIO. Nonresident taxpayers must complete this item to determine the ratio for apportioningthe deductions in lines 16 and 17; certain Schedule Y deductions (see instructions); the exemptions in line 22a; and the EIC in line 45.

a. Total 5.1% income (from line 12). Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14a

b. Interest income (smaller of line 7a or line 7b). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14bc. Total capital gain income, if any (total of Schedule B, Part 1, line 7; Schedule B, Part 2, line 13; Schedule D, line 13. Not less than “0.”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14c

d. Total income this return. Add lines 14a, b and c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14d

e. Non-Massachusetts source income. Not less than “0.” See instructions. . . . . . . . . . . . . . . . . . 3 14e

f. Total income. Add line 14d and line 14e. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14f

g. Deduction and exemption ratio. Divide line 14d by line 14f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14g

DEDUCTIONS. Amounts entered in line(s) 15a and/or 15b must be related to Mass. income reported on this return.

15 a. Amount you paid to Social Security, Medicare, Railroad, U.S. or Mass. retirement. Not more than $2,000 . . . 3 15a

b. Amount spouse paid to Social Security, Medicare, Railroad, U.S. or Mass. retirement. Not more than $2,000 3 15b

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2016 FORM 1-NR/PY PAGE 2

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2016 FORM 1-NR/PY, PAGE 3

FIRST NAME M.I. LAST NAME SOCIAL SECURITY NUMBER

16 Child under age 13, or disabled dependent/spouse care expenses (from worksheet) . . . . . . . . . . . . . . . . . . . . . 3 16

17 Number of dependent member(s) of household under age 12, or dependents age 65 or over (not you or your spouse) as of December 31, 2016,or disabled dependent(s) (only if single, head of household or married filing joint return and not claiming line 16).

Nonresidents multiply result by line 14g;Not more than two: a. 3 × $3,600 = part-year residents multiply result by line 3. . . . . . . . . . . 3 17

18 Rental deduction. Total rental deduction cannot exceed $3,000 ($1,500 if married filing separately). See instructions.

Total Massachusetts rent paid in 2016: a. 3 ÷ 2 = . . . . . . . . . . . . . . . . . . . . . . . . . 3 18

Nonresidents, during 2016 did you have a family home or any other dwelling outside Massachusetts to which you generally or customarilyreturned or intend to return in the future? Yes No. If Yes, you do not qualify for this deduction.

19 Other deductions from Schedule Y, line 18 (enclose Schedule Y). . . . . . . . . . . . . . . . . . . . . . . . . . . 3 19

20 TOTAL DEDUCTIONS. Add lines 15 through 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 20

21 5.1% INCOME AFTER DEDUCTIONS. Subtract line 20 from line 12. Not less than “0” . . . . . . . . . . . 21Exemption amount Nonresidents multiply line 22a by line 14g.

22 (from line 4f) . . . . a. Part-year residents multiply line 22a by line 3 . . . . . . . . . . 3 2223 5.1% INCOME AFTER EXEMPTIONS. Subtract line 22 from line 21. Not less than “0.”

If line 21 is less than line 22, see instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2324 INTEREST AND DIVIDEND INCOME from Schedule B, line 38. Not less than “0.”

(enclose Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 24

25 TOTAL TAXABLE 5.1% INCOME. Add lines 23 and 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

26 TAX ON 5.1% INCOME (from tax table). If line 25 is more than $24,000, multiply by .051. Note: If choosing the optional 5.85% tax rate, fill in oval and see instructions 3 . . . . . . . . . . . . 26

27 12% INCOME from Schedule B, line 39. Not less than “0” (enclose Schedule B).

a. 3 × .12 = . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2728 TAX ON LONG-TERM CAPITAL GAINS (from Schedule D, line 22). Not less than “0.” Enclose

Schedule D. If filing Sched. D-IS, Installment Sales, fill in oval and enclose Schedule D-IS 3 3 28If excess exemptions were used in calculating lines 24, 27 or 28, fill in oval (see instructions) 3

29 Credit recapture amount (enclose Credit Recapture Schedule; see instructions) . . . . . . . . . . . . . . . 3 29

30 Additional tax on installment sale (see instructions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 30

31 If you qualify for No Tax Status, fill in oval and enter “0” on line 32. Complete Schedule NTS-L-NR/PY 3

32 TOTAL INCOME TAX. Add lines 26 through 30 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

CREDITS

33 Limited Income Credit. Complete and enclose Schedule NTS-L-NR/PY . . . . . . . . . . . . . . . . . . . . . . . 3 33

34 Income tax paid to another state or jurisdiction (part-year residents only; from worksheet andenclose Schedule OJC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 34

35 Other credits (from Credit Manager Schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 35

36 INCOME TAX AFTER CREDITS. Subtract total of lines 33 through 35 from line 32. Not less than “0” 36

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37 Voluntary fund contributions:

a. Endangered Wildlife Conservation 3 37a d. Massachusetts U.S. Olympic . . . . . . . 3 37d

b. Organ Transplant . . . . . . . . . . . . . 3 37b e. Mass. Military Family Relief . . . . . . . . 3 37e

c. Massachusetts AIDS. . . . . . . . . . . 3 37c f. Homeless Animal Prevention And Care3 37f

Total. Add lines 37a through 37f . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

38 Use tax due on Internet, mail order and other out-of-state purchases (from worksheet) . . . . . . . . . 3 38

39 Health Care penalty for certain part-year residents. Not less than “0” (from worksheet; be sure to enclose Schedule HC):

a. 3 + b. 3 – c. 3 . . . a + b – c = 39You Spouse Federal healthcare penalty

40 INCOME TAX AFTER CREDITS, CONTRIBUTIONS, USE TAX and HC PENALTY. Add lines 36–39 . . . . 40

41 Massachusetts income tax withheld (enclose all Massachusetts Forms W-2, W-2G, 2-G,PWH-WA, LOA and certain 1099s, if applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 41

42 2015 overpayment applied to your 2016 estimated tax (from 2015 Form 1, line 45 or Form 1-NR/PY, line 50; do not enter 2015 refund) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 42

43 2016 Massachusetts estimated tax payments (do not include amount in line 42) . . . . . . . . . . . . . 3 43

44 Payments made with extension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 44

45 Earned Income Credit: a. Number of qualifying children 3

Amount from U.S. return 3 × .23 = . . . . 3 45

46 Senior Circuit Breaker Credit (part-year residents only; enclose Schedule CB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 46

47 Other refundable credits (from Credit Manager Schedule). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 47

48 TOTAL. Add lines 41 through 47 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

49 OVERPAYMENT. If line 40 is smaller than line 48, subtract line 40 from line 48. If line 40 is largerthan line 48, go to line 52. If line 40 and line 48 are equal, enter “0” in line 51 . . . . . . . . . . . . . . . . 3 49

50 Amount of overpayment you want APPLIED to your 2017 ESTIMATED TAX . . . . . . . . . . . . . . . . . . 3 50

51 THIS IS YOUR REFUND. Subtract line 50 from line 49.Mail to: Massachusetts DOR, PO Box 7000, Boston, MA 02204 . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 51

Direct Deposit of Refund. See instructions. Type of account (you must select one): 3 Checking

3 3

Savings

Routing number (first two digits must be 01–12 or 21–32) Account number

52 TAX DUE. Subtract line 48 from line 40. Pay online at mass.gov/masstaxconnect, or use Form PV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 52

Pay in full. Write Social Security number(s) on lower left corner of check and be sure to sign check. Make payable to Commonwealth of Massachusetts. Mail to: Massachusetts DOR, PO Box 7003, Boston, MA 02204.

Add to total in line 52, if applicable:

Interest 3 Penalty 3 M-2210 amount 33 Exception. Enclose Form M-2210

BE SURE TO SIGN RETURN ON PAGE 1 AND ENCLOSE SCHEDULE HC (IF APPLICABLE).

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SOCIAL SECURITY NUMBER 2016 FORM 1-NR/PY PAGE 4

(Nonresidents, multiply this amountby line 14g; part-year residentsmultiply this amount by line 3)

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FIRST NAME M.I. LAST NAME SOCIAL SECURITY NUMBER

Schedule NTS-L-NR/PY No Tax Status and Limited Income Credit 2016

1 5.1% income from this return (from Form 1-NR/PY, line 12) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2 Adjustments to income (enter the total of Schedule Y, lines 1 through 10) . . . . . . . . . . . . . . . . . . . . . . 2

3 Adjusted 5.1% income from this return. Subtract line 2 from line 1. Not less than “0” . . . . . . . . . . . . . 3

4 Interest exemption used (from Form 1-NR/PY, enter the smaller of line 7a or line 7b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5 Adjusted gross interest, dividends and certain capital gains (from Schedule B, line 35). If there is no entry in Schedule B, line 35, or if not filing Schedule B, enter the amount from Form 1-NR/PY, line 24. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

6 Long-term capital gain income. From Schedule D, line 19. Not less than “0” . . . . . . . . . . . . . . . . . . . . . 6

7 Additional income/loss while a nonresident/part-year resident. See instructions . . . . . . . . . . . . 3 7

8 Total income. Combine lines 3 through 7. Not less than “0” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Additional adjustments to income while a nonresident/part-year resident. See instructions . . . . . . . 3 9

10 Massachusetts Adjusted Gross Income (AGI). Subtract line 9 from line 8. Not less than “0” . . . . . . . 10If you are single and the total in line 10 is $8,000 or less, you qualify for No Tax Status. Fill in the oval on line 31, enter “0” on line 32and con tinue completing Form 1-NR/PY. However, if there is an amount entered on line 29, Credit Recapture Amount and/or line 30,Additional Tax on Installment Sales, enter that amount on line 32 and complete lines 34 and 35. If you are single but do not qualify forNo Tax Status and your total on line 10 is $14,000 or less, go to line 13 to see if you qualify for the Limited Income Credit.

11 If married and filing a joint return, multiply the number of dependents (from Form 1-NR/PY, line 4b)by $1,000 and add $16,400 to that amount. If head of household, multiply the number of dependents(from Form 1-NR/PY, line 4b) by $1,000 and add $14,400 to that amount. If line 10 is less than orequal to line 11, you qualify for No Tax Status. See the instructions for Form 1-NR/PY, line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

12 If you do not qualify for No Tax Status and you are married and filing a joint return, multiply the number of dependents (from Form 1-NR/PY, line 4b) by $1,750 and add $28,700 to that amount.If head of household, multiply the number of dependents (from Form 1-NR/PY, line 4b) by $1,750and add $25,200 to that amount. Enter the result here. If line 10 is less than or equal to line 12,you may qualify for the Limited Income Credit. Go to line 13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

13 No Tax Status threshold. Enter $8,000 if single. If married filing a joint return or head of household,enter the amount from line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14 Income for Limited Income Credit. Subtract line 13 from line 10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

15 Tax before adjustments (from Form 1-NR/PY, line 32 less any Credit Recapture Amount enteredin line 29 and/or Additional Tax on Installment Sales entered on line 30) . . . . . . . . . . . . . . . . . . . . . . . 15

16 Tax for Limited Income Credit. Multiply line 14 by 10% (.10) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

17 Limited Income Credit. Subtract line 16 from line 15 and enter the result here and in line 33 ofForm 1-NR/PY. If line 15 is smaller than line 16, you are not eligible for this credit. . . . . . . . . . . . . . . 17

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File pg. 6SOCIAL SECURITY NUMBER

Schedule DI Dependent Information. Enclose with Form 1 or Form 1-NR/PY. Do not cut or separate these schedules. 2016You must complete this schedule if you are claiming a dependent exemption(s) on Form 1, line 2b or Form 1-NR/PY, line 4b or taking a deduction/credit(s) on Form 1, lines 12, 13 or 41 or Form 1-NR/PY, lines 16, 17 or 45. Complete information below for each dependent. Do not include yourselfor your spouse. If you are claiming more than 10 dependents, see instructions.1. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

2. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

3. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

4. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

5. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

6. FIRST NAME M.I. LAST NAME6

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

7. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

8. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

9. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

10. FIRST NAME M.I. LAST NAME

RELATIONSHIP TO TAXPAYER IS DEPENDENT A QUALIFYING CHILD FOR EARNED INCOME CREDIT?

3 Yes

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